Pathways to Universal Health Coverage: A Qualitative Comparative Analysis of Effective Development Cooperation Principles in Fragile and Conflict‑Affected States

Aweesha, Huzeifa; Pulkki-Brännström, Anni-Maria; Hurtig, Anna-Karin; San Sebastian, Miguel

doi:10.34172/ijhpm.9530

Pathways to Universal Health Coverage: A Qualitative Comparative Analysis of Effective Development Cooperation Principles in Fragile and Conflict‑Affected States

Document Type : Original Article

Authors

Huzeifa Aweesha

Anni-Maria Pulkki-Brännström

Anna-Karin Hurtig

Miguel San Sebastian

Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden

10.34172/ijhpm.9530

Abstract

Background
Universal health coverage (UHC) is a central target of the Sustainable Development Goals (SDGs), yet progress remains limited, particularly in fragile and conflict-affected states (FCAS). Despite commitments to leave no one behind, FCAS face complex circumstances that require better collaboration. Evidence on whether and how adherence to effective development cooperation (EDC) principles influences development outcomes remains scarce. This study examined which EDC principles have affected UHC attainment in FCAS.

Methods
Crisp-set qualitative comparative analysis (QCA) was applied to examine six EDC indicators as explanatory variables (conditions) which are EDC indicators: alignment with plans and budget priorities, partner coordination, national coordination mechanisms, use of national monitoring and evaluation (M&E) system, and provision of joint technical assistance (TA). The outcome was attainment of UHC service coverage index of at least 40. QCA assessed necessary conditions (for outcome to happen they must be present) and sufficient conditions (whenever they are present the outcome happens). We examined 17 FCAS; all were low and low. Seventeen low-income and lower-middle-income FCAS were included, using publicly available 2021 data on conditions and outcome.

Results
While none of the six conditions were found to be necessary for attaining UHC within our data, four appeared sufficient. The final solution indicated that either strong alignment with national plans or joint TA provided a pathway to UHC. The model had moderate coverage of 46%, explaining fewer than half of cases attaining the UHC threshold. Findings should be interpreted considering the small sample size, reliance on self-reported EDC ratings, and crosssectional data rather than assessment over time.

Conclusion
Better alignment among health partners is needed to minimise loss of already scarce and crucial resources in FCAS. Context-tailored TA may support attainment and sustainability of cooperation outcomes. Enhancement of frameworks and measures for tracking EDC and UHC with more frequent monitoring is needed.

Keywords

Effective Development Cooperation

Universal Health Coverage

Sustainable Development Goals

Fragile and Conflict-Affected States

Qualitative Comparative Analysis

1. Kim EM, Lee JE. Busan and beyond: South Korea and the transition from aid effectiveness to development effectiveness. J Int Dev. 2013;25(6):787-801. doi:10.1002/jid.2938

2. Organization for Economic Co-operation and Development. Paris Declaration on Aid Effectiveness. https://www.oecd.org/en/publications/paris-declaration-on-aid-effectiveness_9789264098084-en.html. Published March 1, 2005. Accessed June 11, 2025.

3. Deutscher E, Fyson S. Improving the effectiveness of aid. Finance Dev. 2008;45(3):15-19.

4. Booth D. Aid effectiveness: bringing country ownership (and politics) back in. Conflict, Security & Development. 2012;12(5):537-558. doi:10.1080/14678802.2012.744184

5. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. https://sdgs.un.org/2030agenda. Published 2015. Accessed February 2, 2025.

6. Vandemoortele J. The MDG Story: Intention Denied. Dev Change. 2011;42(1):1-21. doi:10.1111/j.1467-7660.2010.01678.x

7. Wright S, Mabejane R. The 2019 UN high-level meeting on universal health coverage. Lancet. 2019;393(10184):1931. doi:10.1016/S0140-6736(19)30349-6

8. UHC2030. History - UHC2030. https://www.uhc2030.org/who-we-are/history/. Published 2016. Accessed June 11, 2025.

9. World Health Organization. Stronger Collaboration, Better Health: Global Action Plan for Healthy Lives and Well-Being for All: Strengthening Collaboration among Multilateral Organizations to Accelerate Country Progress on the Health-Related Sustainable Development Goals. World Health Organization; 2019. https://iris.who.int/handle/10665/327841. Accessed June 11, 2025.

10. World Health Organization. SDG3 GAP’s Theory of Change. https://cdn.who.int/media/docs/default-source/global-action-plan/sdg3-gap-toc-for-website.pdf?sfvrsn=355ae22c_4&download=true. Published 2022.

11. World Health Organization. SDG3 GAP Monitoring Framework. https://www.who.int/publications/m/item/sdg3-gap-monitoring-framework. Published 2021. Accessed February 5, 2025.

12. Martineau T, McPake B, Theobald S, et al. Leaving no one behind: lessons on rebuilding health systems in conflict- and crisis-affected states. BMJ Glob Health. 2017;2(2):e000327. doi:10.1136/bmjgh-2017-000327

13. Fragile States Index. What Does State Fragility Mean? https://fragilestatesindex.org/frequently-asked-questions/what-does-state-fragility-mean/. Accessed June 11, 2025.

14. Bogale B, Scambler S, Mohd Khairuddin AN, Gallagher JE. Health system strengthening in fragile and conflict-affected states: a review of systematic reviews. PloS One. 2024;19(6):e0305234. doi:10.1371/journal.pone.0305234

15. World Health Organization, World Bank Group. Tracking universal health coverage: 2023 glob-al monitoring report. https://iris.who.int/handle/10665/374059. Published 2023. Accessed February 5, 2025.

16. Gisselquist RM, Justino P, Vaccaro A. Do the principles of effective development co‐operation improve development outcomes? The case for clearer definitions and measurement. Dev Policy Rev. 2024;42(1):e12731. doi:10.1111/dpr.12731

17. Khatri RB, Endalamaw A, Erku D, et al. Contribution of health system governance in delivering primary health care services for universal health coverage: A scoping review. PLoS One. 2025;20(2):e0318244. doi:10.1371/journal.pone.0318244

18. Debie A, Khatri RB, Assefa Y. Successes and challenges of health systems governance towards universal health coverage and global health security: a narrative review and synthesis of the literature. Health Res Policy Syst. 2022;20(1):50. doi:10.1186/s12961-022-00858-7

19. Mello PA. Qualitative Comparative Analysis: An Introduction to Research Design and Application. 1st edition. Georgetown University Press; 2021.

20. Rihoux B, Ragin CC. Configurational Comparative Methods: Qualitative Comparative Analysis (QCA) and Related Techniques. 1st ed. SAGE; 2009.

21. Bazzan G. Qualitative Comparative Analysis (QCA) using R: A Beginner’s Guide. By Ioana‐Elena Oană, Carsten Q. Schneider & Eva Thomann, Cambridge University Press (2021), ISBN: 978–1–009‐00678‐1. Swiss Political Science Review. 2023;29(2):258-259. doi:10.1111/spsr.12560

22. Dușa A. QCA with R. https://bookdown.org/dusadrian/QCAbook/. Published 2024. Accessed April 28, 2025.

23. World Health Organization. 2023 Progress Report on the Global Action Plan for Healthy Lives and Well-being for All. https://www.who.int/publications/i/item/9789240073371. Published 2023. Accessed August 11, 2025.

24. World Bank. Classification of Fragile and Conflict-Affected Situations. World Bank; 2025. https://www.worldbank.org/en/topic/fragilityconflictviolence/brief/classification-of-fragile-and-conflict-affected-situations. Accessed April 30, 2025.

25. World Bank. World Development Indicators. World Bank Open Data. https://data.worldbank.org. Accessed April 30, 2025.

26. Kam CCS, Meyer JP. How careless responding and acquiescence response bias can influence construct dimensionality: the case of job satisfaction. Organ Res Methods. 2015;18(3):512-541. doi:10.1177/1094428115571894

27. Swanson R, Atun R, Best A, et al. Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions. Global Health. 2015;11(1):5-5. doi:10.1186/s12992-015-0090-3

28. Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy Plann. 2009;24(4):239-252. doi:10.1093/heapol/czp025

29. Samb B, Evans T, Dybul M, et al. An assessment of interactions between global health initiatives and country health systems. Lancet. 2009;373(9681):2137-2169. doi:10.1016/S0140-6736(09)60919-3

30. Pfeiffer J, Johnson W, Fort M, et al. Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental Organizations. Am J Public Health. 2008;98(12):2134-2140. doi:10.2105/AJPH.2007.125989

31. Balabanova D, McKee M, Mills A, Walt G, Haines A. What can global health institutions do to help strengthen health systems in low income countries? Health Res Policy Syst. 2010;8(1):22-22. doi:10.1186/1478-4505-8-22

32. Mohamed KS, Abasse KS, Abbas M, Sintali DN, Baig MMFA, Cote A. An overview of healthcare systems in Comoros: the effects of two decades of political instability. Ann Glob Health. 2021;87(1):84. doi:10.5334/aogh.3100

33. World Bank Group. World Bank Supports Comoros to Improve Primary Health Care. https://www.worldbank.org/en/news/press-release/2019/07/02/world-bank-supports-comoros-to-improve-primary-health-care. Published 2019. Accessed August 14, 2025.

34. WHO Regional Office for Africa. Progress towards Harmonization of Partners in the WHO African Region 2023. https://www.afro.who.int/publications/progress-towards-harmonization-partners-who-african-region-2023. Published 2023. Accessed August 14, 2025.

35. World Health Organization. Improving aid coordination in the health sector - Democratic Republic of the Congo. 2015. https://www.who.int/publications/i/item/WHO-HIS-HGF-CaseStudy-15.4. Accessed August 14, 2025.

36. Cordaid. Alignment and coordination of the 3GS in the Democratic Republic of Congo. https://www.cordaid.org/en/wp-content/uploads/2023/05/Policy-brief-Alignment-and-coordination-of-the-3gs-in-the-Democratic-Republic-of-the-Congo.pdf. Published 2023.

37. World Bank. DRC Health Financing Reform for UHC. Washington, DC: World Bank; 2021. doi:10.1596/35955

38. Ministry of Health Eritrea. The second health sector strategic development plan 2017-2021. https://p4h.world/en/documents/the-second-health-sector-strategic-development-plan-hssp-ii-2017-2021/#:~:text=The%20Second%20Health%20Sector%20Strategic%20Plan%20of%20Eritrea%20focuses%20on,threats%20influenced%20by%20climate%20change. Published 2016.

39. WHO Regional Office for Africa. Launching of the Eritrea Health Sector Strategic Development Plan 2022-26 (HSSDP III), Essential Health Care Package, National Action Plan for Health Security 2022-26 (NAPHS). https://www.afro.who.int/countries/eritrea/news/launching-eritrea-health-sector-strategic-development-plan-2022-26-hssdp-iii-essential-health-care. Published 2022. Accessed August 14, 2025.

40. Kanagat N, Chauffour J, Ilunga JF, et al. Country perspectives on improving technical assistance in the health sector. Gates Open Res. 2021;5:141. doi:10.12688/gatesopenres.13248.1

41. World Health Organization. Leveraging the GAP to support the Mali Action Plan on primary health care. 2020. https://www.who.int/news-room/feature-stories/detail/mali. Accessed August 15, 2025.

42. World Health Organization. Reimagining health sector coordination in Zimbabwe: innovation for UHC. 2023. https://www.who.int/news-room/feature-stories/detail/reimagining-health-sector-coordination-zimbabwe-innovation-for-uhc. Accessed August 15, 2025.

43. Trani JF, Kumar P, Ballard E, Chandola T. Assessment of progress towards universal health coverage for people with disabilities in Afghanistan: a multilevel analysis of repeated cross-sectional surveys. Lancet Glob Health. 2017;5(8):e828-e837. doi:10.1016/S2214-109X(17)30251-6

44. Higgins-Steele A, Farewar F, Ahmad F, Qadir A, Edmond K. Towards universal health coverage and sustainable financing in Afghanistan: progress and challenges. J Glob Health. 2018;8(2):020308. doi:10.7189/jogh.08.020308

45. P4H Network. Burundi. July 5, 2024. https://p4h.world/en/countries/burundi/. Accessed August 15, 2025.

46. World Health Organization. 2024 Progress Report on the Global Action Plan for Healthy Lives and Well-being for All. https://www.who.int/publications/i/item/9789240094949. Published 2024. Accessed August 15, 2025.

47. Al-Abdulla O, Alaref M, Kallström A, Kauhanen J. The health system in Syria (2000–2024): assembling the pieces of a fragmented system—A scoping review. Health Res Policy Syst. 2025;23:85. doi:10.1186/s12961-025-01352-6

48. Reich MR, Harris J, Ikegami N, et al. Moving towards universal health coverage: lessons from 11 country studies. Lancet. 2016;387(10020):811-816. doi:10.1016/S0140-6736(15)60002-2

49. Sundewall J, Swanson RC, Betigeri A, et al. Health-systems strengthening: current and future activities. Lancet. 2011;377(9773):1222-1223. doi:10.1016/S0140-6736(10)60679-4

50. Bertone MP, Jowett M, Dale E, Witter S. Health financing in fragile and conflict-affected settings: What do we know, seven years on? Soc Sci Med. 2019;232:209-219. doi:10.1016/j.socscimed.2019.04.019